Sr. Quality of Care Review Nurse

About the role

Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members, through review of services provided to members from network healthcare providers, facilities and Oscar employees. The Senior Quality of Care Nurse analyzes clinical data, tracks core measures, reviews patient records, and implements evidence-based strategies to improve overall provider and facility standard of care. As well as, optimizing clinical experience into clear detailed medical reviews while upholding department standards for quality and productivity. The Quality of Care Nurse Reviewer evaluates and refines healthcare processes to optimize patient safety, clinical outcomes, and regulatory compliance.

You will report into the Nurse Manager, Quality of Care.

Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote

Responsibilities

• Reviewing member complaints that need to be escalated immediately and resolved within 60 calendar days of receipt through review of services provided to members from network healthcare providers, facilities and Oscar employees.
• Perform quality of care review to determine whether records or commentary from the provider/facility will be needed in order to accurately determine whether a quality issue did occur.
• Conduct root cause analyses for adverse events, sentinel events, or potential quality issues to prevent future occurrences.
• Investigate provider and facility quality of care concerns, identifying and escalating negative performance trends for corrective action when appropriate.
• Perform annual medical record reviews for selected states.
• Consult with internal stakeholders to ensure that quality of care needs or members are met while adhering to accreditation and regulatory requirements.
• Present quality and performance trend data to organizational stakeholders, delegates and quality subcommittees as applicable; Collaborate on corrective action plans to address identified gaps.
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements

• Licensed Registered Nurse with active, unrestricted license in state of residence and willingness to obtain additional licenses as needed for Oscar's growth (with Oscar's support)
• 2+ years of experience as a Registered Nurse
• 2+ years experience working in a clinical care setting

Bonus points

• Health plan utilization management experience or case management experience.
• Experience in healthcare quality assurance, including experience auditing medical records and evaluating clinical information and internal documentation to determine the quality of care and service provided to members.
• Experience in health plan case management.
• Bilingual - fluent in Spanish to audit Spanish-language verbal and written interactions.
• Bachelor's Degree from an accredited university, BSN Preferred.
• A working knowledge of health insurance/benefit concepts - Medicare and Individual Marketplace insurance experience a plus.
• Experience with NCQA accreditation standards for utilization management, case management or population health, HEDIS measures and other regulatory requirements.
• CCM or MCG certification.
• Experience analyzing performance and other forms of data.
• Proficiency using Google applications like Sheets, Docs, Slides and Meets.
• Comfortable using Google Meets and other platforms to communicate with internal/external partners.